The present invention generally relates to surgical devices, systems, and methods, especially for minimally invasive surgery, and more particularly provides structures and techniques for aligning a robotic surgery system with a desired surgical site. The present invention describes techniques for mounting, configuring and arranging robotic or configurable set-up arms for the surgical manipulators and endoscope drive mechanisms of a telesurgical system within an operating theater, and methods of improving operating room space utilization in the conduct of a robotic surgical procedure.
Minimally invasive medical techniques are aimed at reducing the extraneous physiologic impact and damage to tissue in carrying out a diagnostic or surgical procedure, thereby reducing patient recovery time, discomfort, and deleterious side effects. The average length of a hospital stay for a standard surgery is significantly longer than the average length for the equivalent surgery performed in a minimally invasive surgical manner. Patient recovery times, patient discomfort, surgical side effects, and time away from work are also reduced with minimally invasive surgery.
In traditional minimally invasive surgery, such as endoscopy, surgical instruments are introduced to an internal surgical site, often through trocar sleeves or cannulas. A body cavity, such as a patient""s abdomen, may be insufflated with gas to provide improved access to a surgical site, and cannula or trocar sleeves are passed through small (approximately xc2xd inch) incisions to provide entry ports for endoscopic surgical instruments. The surgical instruments or tools used in traditional endoscopy may have elongate handles extending out from the cannula, to permit the surgeon to perform surgical procedures by manipulating the tools from outside the body. The portion of the tool inserted into the body may include an end effector, by which tissue is manipulated. Typically minimally invasive procedures are performed under the direction of a surgical imaging system, such as by introducing an endoscope to the surgical site for viewing the surgical field. Typically the endoscope is coupled to a digital camera, to permit remote display, the surgeon then activating the surgical instruments while viewing the surgical site on a video monitor. Similar endoscopic techniques are employed in, e.g., laparoscopy; arthroscopy, retroperitoneoscopy, pelviscopy, nephroscopy, cystoscopy, cistemoscopy, sinoscopy, hysteroscopy, urethroscopy, and the like.
Minimally invasive surgical systems have been and continue to be developed to increase a surgeon""s dexterity by means of robotic telesurgical systems, so that the surgeon performs the surgical procedures on the patient by manipulating master control devices to control the motion of servo-mechanically operated instruments. In contrast to the elongate handles of traditional endoscopic tools, in robotically assisted minimally invasive surgery, or telesurgery, a servomechanism is used to actuate the surgical end effectors of the instruments. This allows the surgeon to operate in a comfortable position without looking one direction (towards the monitor) while manipulating handles of surgical instruments that are oriented in another direction (for example, into the patient""s abdomen). Telesurgical or robotically operated instruments also may greatly increase the range of motion and degrees of freedom achievable for end effectors at the internal surgical site.
As more fully described in U.S. Pat. No. 5,696,837, the full disclosure of which is incorporated herein by reference, a computer processor of the servomechanism can be used to maintain the alignment between hand input devices of the controller with the image of the surgical end effectors displayed on the monitor using coordinate system transformations. This allows the surgeon to operate in a natural position using anthropomorphic hand input devices and motions aligned with the image display, despite the fact that the actual surgical instruments are inserted via otherwise awkward arbitrary access positions. The endoscope may optionally provide the surgeon with a stereoscopic image to increase the surgeon""s ability to sense three-dimensional information regarding the tissue and procedure. Typically the image captured by the endoscope is digitized by a camera, such as a CCD device, and processed for display to the surgeon and surgical assistants.
In robotically assisted surgery or telesurgery, a surgeon typically operates at least one master controller to control the motion of at least one surgical instrument at the surgical site. The controller will typically include one or more hand input devices or masters, by which the surgeon inputs control movements. The master controllers and surgeon""s view display of the endoscope image may be separated from the patient by a significant distance, and need not be immediately adjacent the operating table. The master controller mountings and endoscope display may be integrated as a control console, referred to herein as the xe2x80x9csurgeon""s consolexe2x80x9d portion of the telesurgical system, which may be connected by signal and power cables to the servomechanisms, endoscope cameras, processors and other surgical instrumentation. The console is typically located at least far enough from the operating table to permit unobstructed work space for surgical assistants.
Each telesurgical master controller is typically coupled (e.g., via a dedicated computer processor system and connector cables) to a servo-mechanism operating a surgical instrument. The servo mechanism articulates and operates the surgical instrument, tool or end effector to carry out the surgical procedure. A plurality of master controllers may operate a plurality of instruments or end effectors (e.g., tissue graspers, needle drivers, cautery probes, and the like) based on the surgeon""s inputs. These tools perform functions for the surgeon, for example, holding or driving a needle, grasping a blood vessel, or dissecting, cauterizing, or coagulating tissue. Similarly, surgeon""s master inputs may control the movement and operation of an endoscope-camera driver servomechanism, permitting the surgeon to adjust the view field and optical parameters of the endoscope as the surgery proceeds. In a typical telesurgical system, the surgeon may operate at least two surgical instruments simultaneously, (e.g., corresponding to right and left hand inputs) and operate an endoscope/camera driver by additional control inputs. Note that optionally the servo-manipulators may support and operate a wide variety of surgical tools, fluid delivery or suction devices, electrical or laser instruments, diagnostic instruments, or alternative imaging modalities (such as ultrasound, fluoroscopy, and the like).
U.S. Pat. Nos. 5,184,601; 5,445,166; 5,696,837; 5,800,423; and 5,855,583 describe various devices and linkage arrangements for robotic surgical manipulators. The full disclosure of each of these patents is incorporated by reference. The servo-mechanisms, their supporting/positioning apparatus, the surgical instruments and endoscope/camera of a telesurgical system are typically mounted or portably positioned in the immediate vicinity of the operating table, and are referred to herein collectively as the xe2x80x9cpatient-sidexe2x80x9d portion of the telesurgical system.
Generally, a supporting linkage mechanism is used to position and align each surgical servo-manipulator or endoscope probe with the respective incision and cannula in the patient""s body. The supporting linkage mechanism facilitates the alignment of a surgical manipulator with a desired surgical access point. Such devices will generally be referred to herein as xe2x80x9csetup armsxe2x80x9d, it being understood that a number of quite different mechanisms may be used for this purpose. The above referenced pending PCT/US99/17522, published on Feb. 17, 2000 as WO00/07503, describes a number of aspects and examples of manipulator positioning or setup arms, and the full disclosure of this publication is incorporated by reference.
As an example of a current telesurgical system generally embodying the principles and technology of minimally invasive robotic surgery, reference is made to the da Vinci(trademark) Surgical System, made by Intuitive Surgical, Inc. of Mountain View, Calif., the assignee of the present application.
The present invention generally provides improved methods and mechanisms for configuring and arranging a set-up arms for the surgical manipulators and endoscope drive mechanisms so as to improve and optimize space utilization in the operating room, especially in the telesurgical systems which provide for concurrent operation by two surgeons.
A typical telesurgical system may comprise at least one surgical servo-manipulator mounted to setup arm so as to be positionable adjacent to the operating table for insertion into a cannula placed in an incision in the patient""s body (xe2x80x9cpatient-side surgical manipulators or xe2x80x9cPSMxe2x80x9d). A typical single-surgeon system includes two such PSM, operated simultaneously by the surgeon via right and left hand controller input devices, such as master handles or grips. In addition, a typical single-surgeon system includes an endoscope/camera manipulator (xe2x80x9cECMxe2x80x9d), supporting an endoscope or other endoscopic image capture device, and mounted to a setup arm so as to be positionable adjacent to the operating table for insertion into cannula placed in an additional incision in the patients body.
The telesurgical setup arms, and their respective PSM or ECM, occupy significant volume and require space to have range of motion for positioning. In addition, the environment of an operating room is often crowded with competing demands for space needed for an anesthesiologist, related equipment, surgeon""s assistants, life support equipment, lights, surgical tool storage, instrumentation, displays, and the like. Therefore, one object of the invention is to provide a telesurgical setup arm mounting system which improves space utilization adjacent the operating table.
It is also desired to provide a telesurgical system which permits two-surgeons to operate cooperatively in a dual telesurgical system, including, for example, a total of four PSM and two ECM units, together with their setup arms and supports. Dual surgeon telesurgical cooperative operation is particularly desired for complicated and lengthy procedures, such as multi-vessel coronary bypass graft procedures.
At the same time, it is desired to allow reasonable access to the operating table and related equipment by an anesthesiologist and surgical assistants during the course of surgery. Where two telesurgical systems and respective setup arms are mounted on a separate cart or stand structures positioned adjacent to opposite sides of the table, in addition to the presence of personnel and other surgery-related equipment, the space tends to become quite congested. Therefore, it is another object of the invention to provide a telesurgical setup arm mounting arrangement which minimizes the intrusion by the setup arms into the personnel-usable space adjacent the operating table and which minimizes the potential for xe2x80x9ccollisionsxe2x80x9d or space conflicts with other adjacent manipulators, setup arms or equipment.
In general, the term xe2x80x9cpersonnel-usable spacexe2x80x9d includes space for surgery-related equipment to be positioned adjacent the operating table and space for personnel to stand and move adjacent the table for access to and viewing of the patient and surgery-related equipment. Typically, this includes volumes adjacent the sides and ends of the table from about floor level to include standing headroom. While the manipulators and end effectors of the a robotic surgical system are generally pre-configured to a position adjacent the surgical insertion site on the patient""s body, it is desirable that the setup arms or fixable linkage be pre-configured to be generally clear of the xe2x80x9cpersonnel and equipment usable spacexe2x80x9d, i.e., to extend into this space only minimally so as to couple to the manipulator, the principal part of the setup arm or pre-configuration linkage assembly and mounting base being disposed outside of this space.
Stated in general terms, the patient-side surgical system of the invention comprises a base, a surgical end effector, a jointed linkage supporting the end effector relative to the base and a servomechanism for moving the end effector so as to manipulate tissues. Portions of the support linkage and end effector which are servo-mechanically driven in response to the surgeon""s inputs will generally be referred to herein as a xe2x80x9cmanipulator,xe2x80x9d while portions of the support linkage which are typically manually positioned by assisting personnel are generally referred to as the xe2x80x9csetup arm.xe2x80x9d It should be noted, however, that setup arm joints and links may optionally be powered and moved under computer or operator control during the course of surgery (and before or after surgery), e.g., to optimize manipulator range of motion, to avoid xe2x80x9ccollisionsxe2x80x9d or conflicts between neighboring manipulators, to avoid mechanical singularities, to reduce setup time, to ease storage, and the like.
The exemplary embodiments of the setup arms of the invention are manually positionable or pre-configurable to allow the operator to translate the surgical manipulator and instrument in three dimensions, and to orient the surgical instrument by rotating the manipulator and instrument about one, two or three axes of rotation. The linkages preferably include lockable joints to maintain a fixed configuration and/or position until a brake system is released. While the brake is held in a released mode, the released linkage permits the operating room personnel to manually move the linkage into alignment with the surgical site. The brake system may fix the configuration of these linkages whenever the operator lets go, thereby avoiding inadvertent movement of the surgical instruments.
The linkage and joints of the setup arm system may include position tracking sensors or encoders to permit measurement of motion, position and angles of linkage elements and joints. In the case of manually positionable or pre-configurable (passive) joints, it is preferable that the joint sensors have signals vary with an absolute position of the joint, rather than solely incremental changes in position, to avoid accumulation of possible small position errors. The driven robotic joints may likewise have absolute position, motion or angle sensors. This sensor data may in turn be used for the automatic calculation of the position and alignment of the set arm and manipulators with respect to a selected coordinate system (such as for vision and display alignment), with respect to the range of motion of the setup arm element, with respect to an end effector pivot point, and with respect to neighboring setup arms and manipulators of a multi-arm telesurgical system.
Ceiling Mounted Setup Arm
In one embodiment of the invention, the setup arms articulate from base structures mounted in the ceiling of the operating room, the base structure and much of the setup arm structure being above typical head height, allowing surgical assistant access to the patient and for surgical tool changing with both tables sides unobstructed Furthermore, the setup arms may have a range of motion permitting access to cannula ports over a wide range of the patients body, without modification of the mounting. For example, the ceiling mounted arms may be moved to access both thoracic and abdominal ports. In addition, the ceiling mounting permits the setup arms and manipulators to be retracted out of the way of personnel when not in use. Cabling and power connections may be in the ceiling space, simplifying cable routing. In addition, the ceiling mounting of the setup arms reduces the extent of sterile draping required.
Although multiple setup arms may be mounted to a single ceiling base, where multiple setup arms and manipulators are ceiling mounted (e.g., for cooperative dual surgery), the respective bases may be distributed over the ceiling area to optimize manipulator access to the patient, to avoid conflict with adjacent manipulators, while minimizing conflicts with equipment or personnel located adjacent to floor or table level. The requirements for other ceiling mounted-equipment, such as lights, utility arms, display supports and the like, are considered when selecting ceiling base locations.
In one embodiment, the ceiling mounted setup arm comprises at least one parallelogram-link structure, which is force balanced in the vertical plane by one or more gas-springs. Each parallelogram may be raised and lowered vertically, with minimal residual force, the gas springs being selected to support the majority of the system weight throughout the range of motion. The parallelogram is mounted to a pivot support, providing for rotation in the horizontal plane. Preferably, there are two balanced parallelogram structures in sequence, the distal parallelogram being pivotally jointed to the proximal parallelogram, to permit an additional degree of freedom in the horizontal plane.
Balancing in the vertical plane may be provided by a conventional gas spring of selected dimensions, spring characteristics and mounting points, so as to providing light positioning action, and good force and inertia matching in X, Y, and Z directions. The balance characteristics may be selected to be near-neutral throughout the range of motion, or may be bi-stable, so as to have a predetermined raised and lowered stability points. Optionally, the parallelogram structures may be balanced by counterweights, tension springs, torsion springs, compression springs, air or hydraulic cylinders, torque motors, or combinations of these devices. Alternatively, one or more jointed SCARA-style links may be included, such as are described in the above referenced WO00/07503.
Both parallelogram structures and the pivotal mounting may be lockable, to prevent inadvertent movement once the manipulator is in the selected alignment and position. In addition, one or both parallelogram structures may be powered to assist retraction or deployment. The manipulator (PSM or ECM) maybe mounted to the distal end of the setup arm with additional degrees of freedom for patient side positioning and to avoid xe2x80x9ccollisionsxe2x80x9d or space conflicts with adjacent equipment, such as by a gimbaled or multi-stop mounting. Exemplary mountings of manipulators to setup arms are described in the above referenced WO00/07503.
Floor or Pedestal Mounted Setup Arm
In another aspect of the invention, the setup arm may be mounted to a base support on the floor adjacent to the operating table pedestal or floor adjacent to the table. The mounting is positioned to leave unobstructed floor standing or passage space on each side of the table.
The floor mounted setup arm may have a proximal link comprising a jointed SCARA link providing motion in the horizontal plane. The distal link may be a parallelogram structure similar the that of the ceiling mounted setup arm embodiment, with the gas spring mounted to provide an upward balancing force. As in the ceiling mounted setup arm, the manipulator (PSM or ECM) maybe mounted to the distal end of the setup arm with additional degrees of freedom for patient side positioning and to avoid xe2x80x9ccollisionsxe2x80x9d or space conflicts with adjacent equipment, such as by a gimbaled or multi-stop mounting. The setup arm base support is optionally positioned to permit the arms and manipulators to be stowed under the table structure when not in use.
Combined Ceiling Mounted And Floor Mounted Setup Arm System
In a preferred embodiment of a telesurgical system employing the setup arms of the invention, both floor mounted and ceiling mounted setup arms are included in combination. For example, a dual-surgeon telesurgical system may comprise a total of four ceiling mounted setup arms mounted on opposite sides of the table, and supporting four PSM units. Two floor or pedestal mounted setup arms are included, mounting two ECM units. The combination of ceiling and floor mounted setup arms makes optimal use of available table-side space while permitting the manipulators to be positioned for effective cooperative surgery by two surgeons.
These and other aspects of the invention will be further evident from the attached drawings and description of the embodiments of the invention.